What’s going on with A&E waiting times?

This content relates to the following topics:

Waiting times in accident and emergency (A&E) departments are a key measure of how the NHS is performing, and they generate significant interest. Here, we look at who is using A&E services and why people have been waiting longer in A&E in recent years.  

There are different types of A&E departments

There are three main types of A&E departments in England.

Type 1 departments are what most people might traditionally think of as an A&E service. They are major emergency departments that provide a consultant-led 24-hour service with full facilities for resuscitating patients, for example patients in cardiac arrest. Type 1 departments account for the majority of attendances (63 per cent in 2018/19).

Type 2 departments are consultant-led facilities but for single specialties, for example, dedicated to treating only eye conditions or only dental problems.

Type 3 departments treat minor injuries and illnesses, such as stomach aches, cuts and bruises, some fractures and lacerations, and infections or rashes. Type 3 departments, which can be routinely accessed without an appointment, include minor injury units and walk-in centres.

Major (type 1) and specialist (type 2) departments are operated by NHS trusts. Type 3 departments are operated by the NHS and by the independent sector.

As of March 2020, there were 132 NHS trusts operating type 1 A&E departments. Each trust may operate more than one type 1 A&E department, and, based on audit data from the Royal College of Emergency Medicine, there are approximately 180 individual type 1 emergency departments in England.

There is considerable variation in the activity at different departments. In quarter 3 (October to December) 2019/20, the NHS trust with the most A&E attendances saw more than 95,000 people across its different A&E departments. This was ten times the number of attendances seen in the NHS trust with the least activity over this period (see Figure 1).

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Measuring the performance of A&E departments

The most high-profile measure of A&E performance in England is the four-hour standard. This refers to the pledge in the NHS Constitution that at least 95 per cent of patients attending A&E should be admitted to hospital, transferred to another provider, or discharged within four hours.

Figure 2 shows the emphasis placed on the four-hour standard as 8 per cent of patients are admitted, transferred or admitted in the 10 minutes before they would cause a breach of the standard.

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A&E waiting times are often used as a barometer for overall performance of the NHS and social care system. This is because A&E waiting times can be affected by changing activity and pressures in other services such as the ambulance service, primary care, community-based care and social care services. For example, patients cannot be admitted quickly from A&E to a hospital ward if hospitals are full due to delays in transferring patients to other NHS services or in arranging social care.

Being treated quickly in A&E is clearly important for both the experience and clinical outcomes of patients. However, measuring the proportion of people seen within four hours does not provide a full picture of how A&Es are performing. For example, two different A&Es could see the same proportion of patients within four hours but have very different average waiting times. We should be cautious about placing too much emphasis on the four-hour standard or any single measure of A&E performance. The safety and quality of care, as well as patient experience, are as important as how rapidly care is provided.

In addition to waiting times, the quality of A&E care can also be measured through clinical indicators such as the proportion of patients who re-attend A&E within seven days of their first attendance (9 per cent of A&E attendances in 2018/19 were re-attendances within seven days of the original attendance). Other measures, such as the time a patient waits to see a clinician in A&E, are also now recorded.

The Care Quality Commission (CQC) also rates the safety and effectiveness of A&E services. Urgent and emergency services receive the lowest CQC ratings of core hospital services with more than half being rated as ‘inadequate’ or ‘requires improvement’ (see Figure 3).

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In the 2018 British Social Attitudes Survey, A&E services also received lower satisfaction scores from the general public than other services including outpatients and admitted inpatient care. However, the 2018 national survey of patients who have used urgent and emergency care services shows these services receive high satisfaction scores overall (see Figure 4), although more can be done to improve communication with patients over how long they can be expected to wait and what symptoms they should watch for after they are discharged.

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In 2018, NHS England began a review into NHS access standards including the four-hour A&E standard. This review focuses on whether existing standards – some of which were developed nearly 20 years ago – should be updated or supplemented. Several new standards for A&E services were proposed by NHS England in March 2019, including measures of how long patients wait before assessment or treatment in A&E. These new standards have been tested in 14 pilot sites across England. It was expected that recommendations on changes to the four-hour standard would be proposed in spring 2020, but these proposals have been delayed to later in the year due to the impact of coronavirus (Covid-19).

What has happened to A&E waiting times in recent years?

A&E waiting times have worsened substantially over the past decade, as the NHS has experienced a sustained period of financial austerity and staffing pressures. The NHS has not met the four-hour standard at national level in any year since 2013/14, and the standard has been missed in every month since July 2015 (see Figure 5).

In 2018/19, 88.0 per cent of patients spent four hours or less in A&E, far below the 95 per cent standard. The four-hour standard is measured across all A&E departments, but performance is poorest in type 1 A&Es and this is where the majority of breaches of the four-hour standard occur. For example, in February 2020, 98.6 per cent of patients were seen within 4 hours in type 3 A&E departments but only 73.0 per cent of patients were seen within four hours in type 1 A&E departments.

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It is important to note that the vast majority of patients are still seen within four hours of arrival at A&E. The English NHS also compares favourably with other countries on providing rapid access to emergency care. However, A&E performance has fallen compared to recent years and pressures on services continue to increase.

Why are patients waiting longer in A&E departments?

Patients are waiting longer in A&E departments due to a wide range of factors including rising demand for services and reduced capacity to meet this demand.

Rising A&E attendances

The number of people going to A&E has risen substantially over time. In 2018/19 there were 24.8 million attendances at A&E departments – the equivalent of 68,000 attendances each day on average.

Between 2011/12 and 2018/19, A&E attendances grew on average by 2.1 per cent each year and increased by 3.3 million (16 per cent) in total. This is the equivalent of an extra 9,200 A&E attendances each day. The growth in attendances has been higher in type-3 A&Es, compared to type 1 or type 2 A&Es.

Rising emergency admissions

However, the increased pressure on A&E departments is more closely associated with rising numbers of emergency admissions to hospital rather than the increase in A&E attendances. In recent years, as demand for hospital inpatient care increased, the capacity to meet this demand has come under increasing pressure as the number of hospital beds reduced and the NHS experienced severe staff shortages (see our explainers on A&E waiting times, hospital beds and delayed discharges for more information).

Fewer hospital beds

Patients admitted to hospital require a bed to be available. Although medical advances have reduced the average length of time people spend in hospital and allow beds to be ‘turned around’ or made available again more quickly, rising emergency admissions are placing increasing pressure on a hospital bed stock that has been reduced over the years. Our more detailed recent analysis shows that the number of hospital beds for overnight stays continues to decrease even as admissions continue to rise.

These pressures are demonstrated by high levels of bed occupancy in NHS hospitals, which are closely associated with longer waiting times in A&E. Particularly in the winter months, hospitals are routinely operating with bed-occupancy rates above 92 per cent – the level at which the Department of Health and Social Care suggests that hospitals will struggle to deal with emergency admissions.

One of the clearest indications of the link between A&E waiting times and hospital bed occupancy is the number of patients who experience ‘trolley waits’ in A&E departments – ie, a long wait between a decision to admit the patient being made in A&E and the patient actually being admitted to a hospital bed. The number of ‘trolley waits’ can be affected by variation in how different hospitals arrive at (and record the time of) the ‘decision to admit’. Because of this, NHS Digital has begun to produce data on the number of patients who spend a total of 12 hours or more in A&E. Over the past few years, this number has rapidly increased (see Figure 6). While these extremely long waits represent a very small proportion of the 24.8 million patients seen in A&E last year, trolley waits can cause significant distress for patients and are a clear sign of the pressure A&E departments are under.

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Pressures on other services and changing clinical practice

It has been suggested that one of the causes of increased pressure on A&E departments over the past decade is people attending unnecessarily because, for example, they can’t get an appointment with their GP or are confused about where to go for treatment. In particular, it has been argued that contractual changes in 2004, which removed responsibility for out-of-hours care from GPs, led to an increase in attendances. There is limited evidence to support this theory, with little change in the proportion of attendances at type 1 A&E departments outside working hours (Nuffield Trust 2015).

Delays in discharging patients who are medically fit to leave hospital (known as ‘delayed transfers of care’) are another factor driving up bed-occupancy rates, preventing beds being available for new patients requiring admission from A&E. In January 2020 there were more than 105,000 delayed days in acute hospital care. The majority of delayed transfers (60 per cent in January 2020) can be attributed to delays within the NHS (when there is a delay in patients being transferred to receive care from a different NHS provider such as a community hospital). However, the proportion attributable to social care (ie, patients waiting for care to be arranged at a residential or nursing home or for a care package at home to be developed) has increased over recent years. This reflects pressures faced by local councils, which have seen significant cuts to their budgets in recent years while demand for social care services has been increasing.

Around 9 per cent of people who attend A&E are discharged without requiring treatment, and a further 32 per cent receive guidance or advice only (NHS Digital 2019). This does not mean that all these people are attending A&E unnecessarily or could be cared for elsewhere. For example, someone who leaves A&E without being admitted to a hospital bed may well have attended appropriately because they required assessment or clinical advice from A&E professionals.

Recent analysis has also indicated that waiting times in A&E may be increasing due to advances in medical practice. For example, some patients who would previously have been admitted to hospital can now be fully treated in A&E with more investigations and treatments. Patients with simpler clinical needs who could be treated quickly in A&E may now also be increasingly treated out of hospital, for example, being treated by ambulance services at the scene of an injury. While these advances are delivering better care, they mean that patients attending A&E may spend longer in A&E departments receiving more complex and time-consuming treatment than in the past.

Staffing pressures

A&E departments face longstanding challenges in recruiting and retaining sufficient staff to cope with rising demand. The Royal College of Emergency Medicine notes that emergency medicine has a high attrition rate from doctors in training, high early retirement rates for experienced clinicians, and significant reliance on temporary locum clinical staff. In the most recent General Medical Council survey, nearly three-quarters of emergency medicine trainees rated the intensity of their workload as heavy or very heavy, substantially more than any other specialty.

A range of national policies has been put in place over recent years to boost the numbers of clinical staff in A&E departments through increased recruitment and improved retention of existing staff. Between 2012 and 2019 the number of emergency medicine consultants increased by 7 per cent each year. This has meant the number of attendances per consultant has fallen from roughly 12,300 a year in 2011 to 8,400 a year in 2018. Over this time, other professional roles, such as advanced clinical practitioners and physician associates, have also been developed to play a greater role in delivering A&E services to relieve pressures on departments.

However, it remains difficult to recruit and retain sufficient staff in emergency care and other key services. Shortages of nurses and medical staff are also reported in mainstream specialties such as acute general medicine. Staffing shortages in these key areas will reduce the ability of hospitals to admit patients quickly from A&E departments or to provide specialist advice to patients within A&E departments who could be treated and discharged, further increasing waiting times.

A picture of activity at A&E departments

Age of patients

NHS Digital publishes detailed annual reports of activity at A&E departments in England. These reports show that the age-profile of patients attending A&E has remained relatively stable over the past decade, but people aged 65 and over account for a larger share of A&E activity per head than adults and children (see Table 1).

Table 1 A&E activity by age group
GroupA&E attendancesONS populationAttendances per 1,000 head
Under 18s5,121,24811,954,618428.4
18-6412,278,90133,843,307362.8
65+4,711,43810,179,253462.8

Deprivation

People living in the most deprived 10 per cent areas in England had a far higher number and rate of attendances at A&E compared to other groups (see Figure 8). A&E attendances were twice as high for people in the most deprived areas as in the least deprived.

The first large-scale research into attitudes and perceptions towards emergency care from the 2018 British Social Attitudes Survey found people living in deprived areas: are more likely to prefer A&E departments over their GP to get tests done quickly; find it more difficult to get an appointment with their GP; and think A&E doctors are more knowledgeable than GPs.

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Conditions

One of the defining characteristics of emergency medicine (and general practice) is its undifferentiated case-mix, ie patients attend an A&E department without prior testing or categorisation of their medical condition and health needs. Figure 9 shows the wide variety of conditions that are treated in A&E departments.

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Discharge

Nearly 60 per cent of A&E attendances end with the patient being discharged, with slightly more than 16 per cent of patients being admitted to hospital and smaller proportions of patients being transferred or referred to other services. More than 40 per cent of patients arriving by ambulance are admitted to hospital from A&E, compared to only 9 per cent of patients who arrive by other means (including self-referral and transport) (see Figure 10).

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Winter pressures

Winter is the one of the most challenging times for health and care services in general and A&E departments in particular.

Although the volume of A&E attendances is not substantially higher in winter, the demand for hospital admissions and more intensive medical care increases. Demands can rise due to increased prevalence of influenza-like illness, respiratory diseases associated with colder weather such as asthma and pneumonia, and infectious winter vomiting bugs like norovirus.

These pressures also affect NHS staff, further adding to pressures on services as staff sickness increases over winter. The supply of hospital beds can also be heavily affected by norovirus outbreaks, which can lead to entire wards being shut and deep-cleaned. This combination of increased demands and reduced capacity leads to patients waiting longer in A&E departments over the challenging winter months.

Each year NHS organisations and local groupings of organisations in ‘A&E delivery boards’ produce plans of how they will increase capacity and cope with rising demand. These include: using any additional government funding to help the NHS cope over winter (over the past decade, it has become common practice to give the NHS additional funding for winter pressures – and this funding often comes at short notice.); opening temporary ‘escalation beds’ to admit patients when demand surges; and cancelling planned operations to allow staff and hospital beds to be prioritised for patients arriving at hospital in an emergency.

However, as staffing pressures and reductions in the number of hospital beds have become endemic to the NHS over recent years, long waiting times in A&E departments throughout the year are common.

Conclusion

While rising demand for services means that the NHS is treating more people than ever before, patients are waiting longer for the care they need in A&E departments.

A&E departments have constant interactions with other parts of the hospital, for example, to request diagnostic tests and to transfer patients. A&E performance is therefore dependent on processes and capacity in other hospital departments, as well as other parts of the health and care system. High levels of hospital bed occupancy, delays in transferring patients out of hospital, and staff shortages throughout the urgent and emergency care system have all had an impact on A&E waiting times. The four-hour A&E waiting time standard is one of the most high-profile indicators of how the NHS is performing. The declining performance against this waiting time standard is a clear indication of the pressures the wider health and care system is under.

The new five-year funding deal for the NHS provides welcome relief after the longest funding squeeze since the NHS was established. However, it will not provide enough resources for performance to recover against these standards while also developing new and better services. Taken alongside staffing shortages, this means there is little prospect of waiting times in A&E departments being restored to previous levels or the national standard in the near future.

NHS waiting times: our position

Performance against key national waiting time standards has deteriorated in recent years, leaving many people waiting longer for care; there is little prospect of recovery in the foreseeable future.

Learn more

Comments

Umesh Prabhu

Position
Medical Director,
Organisation
Wrightington, Wigan and Leigh FT
Comment date
08 April 2014
I am very fortunate to have amazing AE staff and a fantastic CD. Got a brilliant CEO and the Board. But AE middle grade doctors shortage and Consultant shortage is killing us and our performance. When there is a shortage quality of doctors drops and cost increases. Neighbouring Trusts are trying to pouch our consultants with more pay!

It saddens me that many of Australian AE training posts are filled by UK graduates. It also saddens me that there are nearly 50% AE middle grades who are non-trainee posts. Traditionally these are filled by non-EU doctors from Indian and African countries. With the immigration changes these doctors have stopped coming to UK.

While we bust the myths let us also see what is the solution for acute shortage of AE doctors, why our trainees are happy to go to Australia but don't want to do their training in UK and let us learn lessons.

We owe it to our patients and also for our staff. If not quality will drop, cost will increase and both patients and staff will suffer.

Carol Morgan

Position
Working with manufacturing company,
Comment date
08 April 2014
Good afternoon

I am very sad and also somewhat resentful that doctors are going to Australia.
I am visiting my daughter in Melbourne very soon having been their for three and a half months in 2011.
I was surprised to discover how much must be spent on admin in the Australian system.As a patient with Medicare I had to either pay the total amount and then claim a large percentage back via a Medicare office or fill in many forms or or if they bulk billed then I had to pay the percentage required at the surgery.
One young Australian said he would not take his children to A@E in Melbourne as there would be too much blood??
WE do not hear of the problems in otherrcountries. I have a relation in Vancouver and she had to wait for three days on a trolley in a corridor as they did not have a bed to admit her.
I intend doing some research whilst I am in Australia to find out just exactly how it works.

I wish you all the very best.PS I was admitted to hospital as an emergency ,spent four days there and received surgery eight weeks later. Excellent all round

CR

Comment date
08 April 2014
In response to "myth 3", I remember reading this last year:

http://www3.imperial.ac.uk/newsandeventspggrp/imperialcollege/newssummary/news_12-6-2013-12-2-28

Russell B Hamilton

Position
Experienced healthcare professional,
Comment date
09 April 2014
This is an excellent paper. It is good to see a thoughtful and well set out analysis of reality addressing the myths that continue to be promoted by people who to be frank are either ill informed or manipulating the facts for political gain.

Much of what is described in this paper is common sense when looking at the impact of policy decisions, investment, geographical pressures, training and recruitment issues and inescapable demographic changes and pressures.

My experience of working in primary, acute and ambulance services at a senior level and at a more remote strategic level tells me that the vast majority of all staff go to work and do a great job with what they have and that there are a great many who are innovative and creative.

The simple fact is that this as your paper highlights a complex area with an incredible number of variables.

It is important to be realistic and honest about what is not only affordable but what is achievable taking into account all the available resources.

Well done again. Keep up the great work - busting the myths and highlighting the issues.

Will Denby

Position
GPST,
Organisation
Wessex
Comment date
14 April 2014
As a trainee about to embark on a career in the NHS, I am excited. In the coming years we have a fantastic opportunity to make the NHS even better than it already is as a fully-comprehensive health service, free at the point of delivery. We should be bold, and make the NHS as good as it can be, for everyone - it might look very different in years to come.

The 'front door' issues make the headlines, but there are untold triumphs and issues lurking beneath that do not get the political and press coverage.

We have an opportunity as clinicians to work with all stakeholders at trust and strategic level to address these issues, with the patient at the centre of the whole scenario - the QIPP savings will follow!

I too enjoy reading the Kings Fund's measured take, on what can be at times a visceral discussion about the future of the NHS, inevitably tarnished with whatever political hue one would wish - a nessecary evil in a system borne by politicians.

Keith Hider

Position
Healthcare manager,
Comment date
24 April 2014
"nearly 40 per cent of patients who attend A&E are discharged without requiring treatment." I continue to be astounded by this statistic and fail to understand the behaviour of people who have nothing wrong with them wasting their time sitting in a A&E waiting room. What does this statement actually mean - these people needed no treatment, no reassurance, nothing? Or does it mean they were discharged directly from A&E without the need for any follow-up treatment? Please explain.

James Thompson

Position
Senior Research Analyst,
Organisation
The King's Fund
Comment date
24 April 2014
Keith, thanks for the comment/question. This stat originates from the A&E Hospital Episode Statistics (HES) data and was part of the Health and Social care Information Centre (HSCIC) report: Focus on A&E.

We have taken the number used in the data sheet that accompanies the HSCIC report that says: 39% of patients were discharged with no follow-up required. So they could have consumed lots of activity before they were discharged, but with no further treatment required.

But the Focus on A&E report says that, for first A&E treatment, 34.4% of patients received guidance/advice only. So perhaps the true number of patients receiving no treatment is somewhere between the two.

I do think however that we need to be careful about how we class 'guidance only'. Though it is likely that this advice could be given in other healthcare settings, we shouldn't discount its value to patients who felt they needed to see a healthcare professional at short notice.

Diana Badcock

Position
ED Director,
Organisation
Australian Healthcare Group
Comment date
22 May 2014
UK citizens have reciprocal Medicare rights in Australia
We have private and public ED's however it is common for the more electronically advanced ED's to charge overseas visitors $400 for an attendance and the you would be eligible to get some of that back from Medicare and the rest from a private insurer ( if you have taken out that level of travel insurance before you travel). Those ED's not so well resourced would likely charge the Medicare rebate only. However Australain health care is based on user pays- we pay for scripts, always GP visits, unless you go you a bulk billing clinic. This is the way it works.
There is no NHS philosophy here for those who can pay and if you are fortunate enough to be able to afford to visit Oz -you pay.
If you have a life threatening illness all bets are off and any ED will ignore all of the above and care for you- even top private ED's would not chase the dollar - if you needed heart surgery after a heart attack they would get on with it and suck it up. This is not infrequent.
TAC - transport accident commission would cover all costs if you are injured on our roads
WC - work cover would cover all costs if you got injured at work
DvA - would cover all costs if ever you out your life on the line for fellow countryman
It's different to the UK but it's not a bad system.
Do not travel and expect fish and chips- unfair. We would grill the fish and have salad and you would feel healthier afterwards.
Enjoy Melbourne- my family have enjoyed my deflection to Oz 25 years ago and on their visits to Oz have needed to utilise the services occasionally and loved it -
Advice. IF YOU PICK UP A MEDICARE CARD FROM A MEDICARE OFFICE AS SOON AS YOU ARRIVE IN THE COUNTRY- to which you are entitled - IT IS LIKELY YOU WILL BE CHARGED NOTHING IF YOU ARE SICK ENOUGH TO NEED ED. You will need to pay a copayment at the GP as everyone does. Unless you go to a bulk billing clinic.
As to why the registrars are coming- look at the case mix and skill base they get here. The days of Oz coming to practice on the POHM's is over. POHm's come here because the training model for ACEM is different and the lifestyle and attitude is wonderful for anyone.
Don't moan that they come- find out what we offer and take it back to UK

Dr E Partington

Position
GP,
Comment date
14 October 2014
It's not surprising that newly qualified A and E doctors go abroad- the working conditions here are dreadful. Rotas are very hard, long days , maybe 9 days in a row. It's difficult to choose your area to be near your family. Holidays have to booked a year in advance, with poor HR support. Colleagues tell me how despairing they become.....we have fantastic , enthusiastic graduates then we exhaust them; they deserve better.

Stephen Praibin

Position
Healthcare workflow analyst,
Organisation
NSW Health
Comment date
17 December 2014
Just reading with some skepticism the claim that lots of nurses and doctors from the UK are filling positions in Australia...
The reverse is true. A number of representatives from UK hospitals and government agencies have been recruiting here for UK roles. The money is better in the UK and the bureaucracy problem is less.
The issues we have are globally universal:

Trauma doctors and experienced nurses are in short supply.
Growth in aged care health is growing very quickly
Trolley block is being addressed to avoid ambos being stuck at emergency departments waiting for a A&E bed.

Whats new? Every country has these problems. Doctors and nurses in Australia are paid roughly the same as in the UK if you analyse the higher living costs in Australia and purchasing power.

Stephen
Sydney Australia

Colin Garrod

Position
Consultant,
Organisation
Savience
Comment date
06 January 2015
I find it incredulous when there is an IT system designed specifically for Emergency Departments which;

Relieves the burden on NHS Administrators and Nursing staff
Releases them to focus on caring for patients
Pays for itself quickly and then saves money
Patients love it
Directs patients to the most appropriate health provider
Is already being used by an A&E department in England for 2 years

AND YET WHEN THIS IS INTIMATED TO NHS ENGLAND THEY DON'T BELIEVE THE EVIDENCE BASED STATISTIC ABOUT THE BENEFITS - BECAUSE IT IS "TOO GOOD TO BE BELIEVED" !!!!

Leon Duveen

Position
IT Consultant,
Organisation
Rayton Consutancy
Comment date
06 January 2015
Mr Garrod, All NHS Hospitals I have worked with in the last 15 years have had an IT System for A&E, some better than others I agree, most designed specifically for A&E departments. To suggest they don't and only the Savience System is worthwhile is tendentious to say the least

Ganye

Position
Research Student,
Organisation
Southampton University
Comment date
09 January 2015
I don't understand all these “myths”. Are you saying here that all these problems of delays, congestion and pressures in the A&Es and GPs don’t exist? What are then the real problems affecting the A&E since all the problems known tend to be myths?
You write, "Nearly 40 per cent of patients who attend A&E are discharged without requiring treatment. This does not mean that all these patients are attending A&E unnecessarily or could be cared for elsewhere." What does that mean? Is the A&E designed for people to just stroll in and waste queue time and causing nothing to the system? How is healthcare delivered in the UK- what are the processes?
According to the Foundation trust network, there are systemic problems affecting the NHS see for example http://www.nhsconfed.org/news/2015/01/a-e-performance-indicative-of-intense-pressures-across-system
The Foundation Trust Network also presented problems affecting the NHS and the A&E here http://www.publications.parliament.uk/pa/cm201314/cmselect/cmhealth/171/171vw31.htm#footnote_1
Besides there are other studies that have shown that access to GPs reduce the amount of “unwanted” A&E attendance. See for example
• Inappropriate attendance in A&E by Wise (Wise, 1997)
• Inappropriate attendance in A&E (Murphy, 1998)
• An evaluation of the reasons why patients attend a hospital Emergency Department (Land and Meredith, 2013)
• Access to primary care and visits to emergency departments in England: a cross-sectional, population-based study (Cowling et al., 2013)
• And many more studies
Are there problems within the A&E and GPs operations and within the process of healthcare delivery in the UK? Looking at the data and reports, I feel that there is. What do think? If you see only myths, what are the real problems them or is it that they don’t exist?

Cowling, T.E., Cecil, E.V., Soljak, M.A., Lee, J.T., Millett, C., Majeed, A., Wachter, R.M. and Harris, M.J. (2013) Access to primary care and visits to emergency departments in England: a cross-sectional, population-based study. PloS One, 8 (6), 1-6.
Land, L. and Meredith, N. (2013) An evaluation of the reasons why patients attend a hospital Emergency Department. International Emergency Nursing, 21 (1), 35-41.
Murphy, A.W. (1998) 'Inappropriate'attenders at accident and emergency departments I: definition, incidence and reasons for attendance. Family Practice, 15 (1), 23-32.
Wise, M. (1997) Inappropriate attendance in accident and emergency. Accident and Emergency Nursing, 5 (2), 102-106.

Anna Tatton

Comment date
10 January 2015
This article has incensed me. It is lazy, out of date, misleading, patronising garbage. The 'myths' you describe are true! Please take down this rubbish.

Beccy Baird

Position
Policy Manager,
Organisation
The King's Fund
Comment date
14 January 2015
Thanks to all those who've taken time to comment - we've now refreshed the content to reflect the latest developments and we'd welcome your views on the questions we've raised here.

James Allen

Position
Healthcare Assistant,
Organisation
NHS (Basingstoke and North Hampshire Hospital)
Comment date
15 January 2015
Great article, sums up the situation nicely. I work on an acute ward and I wholly agree with the statement that the official number of delayed discharge patients is the tip of the iceberg. Out of 28 patients on any given day at least 5 (often more) are medically fit and are waiting on a package of care, equipment to arrive at home or just need more physiotherapy before they are fit to go home. All of these are a supply and demand issue.

We have a dedicated ward (in a separate building) for physiotherapy but it is nowhere near large enough. If it was larger, or if there were more places like it, then the flow of patients out of acute wards could be increased. The problem all comes down to money. If halfway wards for PT and OT were built than less could be spent elsewhere.

What we really need is more options for patients so they can be discharged from acute wards. More dedicated rehabilitation facilities for medically fit patients, more carers in the community, better integration with nursing homes so it is quick and easy for families to choose a home and for nursing assessments to be made, and a better supply of equipment so patients can receive care at home if they wish.

Bobbie Jacobson

Position
Senior Associate, epidemiology,
Organisation
Bloomberg School of Public Health, Johns Hopkins
Comment date
15 January 2015
Thank goodness for the Kings Fund. some good myth-busting here. Two further questions to address:
1. How much has the non-medical advice at 111 contributed?

2. You need to look for better evidence of patients being sicker eg multiple diagnoses etc.

Peter Weaving

Position
GP Clinical Director,
Organisation
North Cumbria University Hospitals Trust
Comment date
15 January 2015
The last three cardiac patients I saw in the ED where I also work I discharged two home with no further treatment but they had bloods, cannulae, ECGs including monitoring and x-rays - mainly to exclude further coronary events - but technically sent home with no treatment.

Kadiyali M Srivatsa

Position
Retired GP,
Organisation
NHS
Comment date
15 January 2015
I went through the article and know why A&E is in a bad situation that will get worse as emerging infections and antibiotic threat escalates.

I tried to answer some of the questions some tn years ago and so went through A&E documents, compiled a list of common presenting symptoms in GP surgery, OOH NHS Direct clinic, Private healthcare in Harley Street, RAF and Island (Isle of white) before I developing my tool called MAYA. (Medical Advice You Access). People who are compiling statistics in A&E and clinic know the documents are not clear and so the statistics are often wrong.

When I did this work, I have seen doctors diagnosis documented as snuffles, cold, flu, chesty, vomit, URTI, LRTI, UTI and all sorts of rubbish. I have also identified numerous mistakes that NHS was not happy to hear. I raised concern, informed GMC, BMA, NMC and Royal Colleges but none wanted to hear what I had to say.

The kind of work I did was not retrospective and so is accurate and likely to be helpful to resolve the crisis. Only way you can know what is going on and how to solve this problem is to start similar study and not use old data. If you want to help, why not ask doctors (clinicians) like me, who worked as staff doctors or registrars and not professors or consultants. I think Peter Gill has highlighted the problem well and Colin Powell has also suggested changes (Arch Dis Child 2013).

I am sure you will know hear more about this when I appear in the high court because I have taken legal action against NHS for harassing me for doing my duty to protect fellow human.

Kadiyali M Srivatsa

Position
Retired GP,
Organisation
NHS
Comment date
15 January 2015
Please watch my video Elephant In The Room, in Youtube that explains the reasons why Emergency care and A&E in NHS is in crisis. I have also developed a solution that can help save NHS. Please leave comments and tell me I am wrong or pat me on my back and offer your support. Its the life of innocent people who access emergency care and visit hospital A&E we must think of and not NHS.

Kadiyali M Srivatsa

Position
Retired GP,
Organisation
NHS
Comment date
15 January 2015
Hi Dr Garrod, please let me know who has developed this IT programme because I have shared information with the PM, Health minister after I produced a simple fridge magnet that could reduce access by 60%-80%. I have also produced an APP that could educate and keep patients away from hospital. My work is copy right and patent protected because I did not want IT companies to steal and abuse it to commercialise this programme.

The reason I am not releasing in App store is because this tool will make doctors loose control. If I don't succeed in doctors accepting my work and using to help them selves and their patients, then the I am planning to publish a book and sharing my apps.

Please note I have used the same logic approach to differentiate minor from serious illness for 30 years when I worked in major NHS hospitals. Please note I am still register and licensed to work as a doctor and GP in UK but am too scared to return to work in the NHS.

Thank you for sharing the information.

Tryphaena Doyle

Position
Programme Director Systems Resilience,
Organisation
NHS Kernow
Comment date
15 January 2015
It is good to see workforce groups other than just ED Drs. Shortages or nurses, therapists and other Drs on hospital wards must impede productivity, adding time to a patients time in hospital. Has this been looked at? Similarly, what is the impact of shortages of social care staff - how has this changed over time

Angrydoc

Position
Consultant Emergency Physician,
Comment date
15 January 2015
It's disappointing that even the King's Fund seems to struggle with what the 4 hour standard measures. It's nothing to do with waiting to be seen - it's time from booking in to either admission to hospital or discharge. The media doesn't get it, politicians don't get it - and the widely respected King's Fund doesn't get it either.

The last thing we need is scaremongering and, in this election year, we'll get enough of that from politicians without think tanks joining in.

Dr David Ellis

Position
Hospital Public Governor,
Organisation
Warrington and Halton Hospitals
Comment date
17 January 2015
As a hospital governor, I have been following the development of the current A&E "crisis" with interest. (I must point out that I have no medical background - I am a scientist and marketer by background.) There are clearly many contributing factors, some more important and others less important. One aspect which I feel is of special relevance is the fact that more patients are presenting with complex needs. These are mainly older patients who represent the majority of hospital admissions (two thirds). Indeed, these poorly patients are often "blamed" for the woes we are facing with an ageing population. There are several aspects to this which I think are relevant. First, these patients are going to be more complex to discharge as they are more likely to need support. Secondly, they are more likely to be readmitted within 30 days, and indeed thereafter, unless their multiple conditions are well controlled. Over the past couple of years, GPs have come under increasing pressure. In hospitals, when A&E targets are not met, there is increasing pressure to reduce length of stay. With these two scenarios, it seems to me that the focus of both groups of doctors is going to be increasingly on the single condition which caused the visit to their doctor or to the hospital. We also know that a significant percentage of readmissions are not due to the cause of the original admission. This strongly suggests to me that what is really needed is a much more holistic approach to the patient which can help to not only keep them out of hospital, but significantly improve their quality of life too. This requires more time to be spent with the patient and listening to them to gain a better understanding of their health and possibly making adjustments to their medication, self management etc. This time investment will provide a clear financial return on investment with fewer GP visits in the end and fewer hospital admissions. There is also value in the patient being looked after in hospital by a generalist who can bring in specialists as needed. This would give more continuity and would help to identify other factors that might impact on the patients health other than the specific condition they had on admission. Finally, there needs to be much more involvement of patients in managing their own conditions and involving their family/unpaid carers too, especially where they may suffer cognitive impairment. This will help ensure proper support and ensure that medications are taken properly without confusion. We need to help older people lead healthier and more fulfilling lives. In the end, any cost will be more than repaid. I believe that many of the cuts we have seen in the last three years have had the opposite effect. I would be interested in any views.

sharon paterson

Position
retired a/e staff nurse,
Organisation
none
Comment date
22 January 2015
As a relatively fit 65 yr old-I am pretty fed up with the simplistic blaming of the current situation on the elderly population. I think Jeremy Hunt needs to clear up the belief that most patients attending a/e are old-this is not statistically correct-however-correctly-those that do attend often have multiple needs-the fractured neck of femur caused by uti,and poor electrolyte control ,allied with complex cardiac problems.We are,to some extent the victims of our own success,but I hear the most appalling stories of poor basic care [lack of close watching over fluid+ nutrient intake when patients eventually are admitted],and allied with the reduced mentorship of inexperienced nurses by more senior clinically trained staff[as hinted at by Mal,in the previous post],we have the makings of the "perfect storm"we we are indeed now experiencing. As for doctors going to OZ-who wouldn,t, when they can see perhaps a more optimistic future there -especially if they have children. I for one,am heartily fed up with the regular electioneering promises-no-one has sorted the NHS-and I worked 40 years at the coal front,so know what it feels like

Sunaina

Position
Service Manager,
Organisation
Kings College Hospital
Comment date
04 February 2015
A really good paper. There are a number of issues that affect A&E. The key being the reductions in Length of Stay ( beds get closed for effeciency) are not in praportion to the increase in acuity causing flow issues within the department. This creates difficulties in seeing patients which then impacts the environment for the clincial staff creating a negative pressure that starts eroding morale. A very vicious cycle.
Effeciencies are needed in every system but in an emergency pathway they need to be looked at by experts within the field as an entire pathway issue with ideas, suggestions and clear next steps. Am not suggesting papers here - just requesting for clearly thought through suggestions. No am not teaching a 'granny how to suck eggs' but how when a group is battling staffing issues, flow issues resulting in performance issues, change fatigue and simple exhaustion how can they see clearly and those that are not in the system can they really comment on the system??

Mark

Comment date
02 March 2015
Interesting but it would have been useful to consider why certain cohorts do turn up to AE . My sense around this is that younger people tend to use AE disportionatrly- I suspect it's cultural - like difference between a mobile phone and landlines- if I am right then GP practice in its current form probably won't be sustainable over the long term

Ken Smith

Position
Retired,
Comment date
23 August 2015
The report is inmost parts sound with in my opinion one exception .. The back up for elderly people leaving A&E after treatment is none existent
Elderly leave with no idea on who to contact especially at weekends .
To leave a 77 year old Man to look after his74 year old wife who is in pain and inconinant where he had to nurse her 24 hours day and night so that he was at his wits end to know what to do shows how the systems and billions of pounds given are not reaching the front line.

Jackie Brook

Position
journalist,
Organisation
Careindustrynews.co.uk
Comment date
28 January 2016
I don't feel this article actually confronts reality at all. All the figures shown are readily available under the Freedom of information and therefore anyone could have worked out the figures.
You haven't burst the singular and most important myth. The mainstream media refers constantly to waiting times being longer and more and more people attending A&E. The government have spent many hundreds of thousands of pounds putting the message across that we require 24/7 care deliverable via A&E implying that Doctors and emergency staff are failing to pull their weight-This is not only wrong, it's an out and out lie. There's only one reason that queues are getting longer and that's because over 70 A&E departments are closing or have been closed exposing many UK residents. It's happening by stealth and as an independent charity you have let down your subscribers by not exposing the truth. A disappointing read that really could have exposed the PFI reality which is breaking the NHS!

The Beast

Position
Registered Nurse,
Organisation
agency
Comment date
30 January 2016
As a registered nurse of 23 years, 16 years working in A&E depts. I have worked in 13 different A&E's, I can only offer anecdotal comments through my observations:

Community care and social care is mostly inadequate.
CCG's have very little insight into the services they commission.
The four hour target is widely manipulated and not collated by trusts as per DOH guidance.
NHS 111 is variable in quality, dependent on which company runs the contract for an area.
A&E nursing is a dying skill, now predominately occupied by pole climbing sycophants more worried about targets than emergency presentations.

It only leaves me to think that politicians of all colours are eager to sell as much of the NHS off to their rich chums, using unsustainability as the reason.

The Beast

Position
Registered Nurse,
Organisation
agency
Comment date
01 February 2016
I totally agree Jackie. The closure of so many A&E's has meant the overall loss of acute admission beds. The subsequent pressure on the A&E's that remain is unsustainable. The overwhelming number of admissions to hospital via the A&E route are under the care of the on call medical team, mostly older people with co morbidities and subsequent complex care needs. The current situation of pushing too many people through a system that is under strain will lead to poor outcomes for some of the most vulnerable people.

Sarah

Comment date
05 March 2016
I agree from a patient point of view the Australian system is a pain - there are some massive inefficiencies and distortions in the Medicare system BUT from a workforce point of view, unfortunately for NHS A&Es, the working conditions are much better and the standards of care are extremely high.

Beverley Marriott

Position
Community Matron,
Organisation
Birmingham Community Healthcare Trust
Comment date
07 March 2016
What's going on in A&E?
Currently working as part of a 'front door' team - I find this a great read. Currently involved with a project looking at integration across primary secondary and tertiary servives as part of Older Persons Fellowship Kings College - this gives great evidence to support this

Faye Creed

Position
Registered Manager,
Organisation
Workwise Healthcare Ltd
Comment date
07 March 2016
As there appear to be too many people turning up in Accident and Emergency with trivial complaints would it not be sensible to have a rapid response team in each G.P. surgery where patients could be spoken to over the telephone and triaged to the appropriate health care professional according to priority of presenting symptoms. This might also reduce the problem of ambulance handover log jams in Accident and Emergency and free up ambulance personnel. However there would have to be a shift of resources. Furthermore hospitals should provide a discharge care plan for individuals to avoid rebound admission with the same problems further down the line.

Dr David Walker

Position
Professor, Emergency medicine,
Organisation
Queen's University and affiliated teaching hospitals
Comment date
07 March 2016
In a many decades long career in EM I have seen and discharged many people without treatment (other than providing advice and reassurance). Good examples include the person with chest pain or symptoms that might represent stroke (whom we urge repeatedly to attend A&E). Our issues (at least on this pond side) are mainly due to the challenges of a health system poorly equipped or transformed to address the needs of the frail elderly for whom the ED becomes the default when a wheel comes off

Roger Steer

Position
Director,
Organisation
Healthcare Audit Consultants
Comment date
07 March 2016
What I do not understand is the insouciance with which the Kings Fund reports these issues.
1. If graphs of the trends in type I attendances were shown separately it would better reflect the detriorating situation.
2. The figures fly in the face of plans to dramatically reduce the level off attendances by the development of out of Hospital services.
3. The proportion of resources spent in A&e remains very small as a proportion of total. The refusal to match demand with resources seems perverse.
4. The shortages in junior and trained medical staff has been a deliberate policy to justify rationalisation.
5. little mention is made of the problems in nursing homes, social care and housing and their contribution to the problem.

Nick Moor

Position
Partner, Investigation & Reviews,
Organisation
Niche Health & Social Care Consultancy
Comment date
10 March 2017
Thanks for an interesting article. Id be interested in getting an understanding of how much people with mental health problems contributes to this. Any ideas?

Dr Rodney Jones

Position
Statistical Advisor,
Organisation
Healthcare Analysis & Forecasting
Comment date
13 March 2017
It would be nice if the Kings Fund did a summary of recent publications. For information regarding attendances by people with mental health conditions (plus many other conditions) refer to http://www.sciencedomain.org/abstract/16193, another useful source on the effects of high bed occupancy is available at http://www.hcaf.biz/2010/Publications_Full.pdf which also covers analysis of trends in emergency admissions. Hope this helps.

stephen smith

Position
retired,
Organisation
Imperial College
Comment date
20 May 2017
I couldn't find the relation between population size and type of A&E. If three hospitals are having their services redistributed as in Chelmsford (population predicted for 2017: 172,755), Basildon (population predicted for 2017: 186,247) and Southend (population predicted for 2017: 181,665) how is the requirement for A&E determined? These A&Es arose originally because of need, presumably, and there are other factors such a transport problems (congestion) and for Southend, a nearby busy airport and coastline, and influx of tourists in summer.

Sam Chapman

Position
Managing Consultant,
Organisation
Clarity Consulting Associates Ltd
Comment date
26 June 2017
Having delivered successfully the 4-hour target in ED departments you won't be surprised to hear that I believe this article to be a bit simplistic. Not a criticism but it is a very high level look at some of the issues in ED.

The target is completely achievable and when where it is achieved you'll reduced length of stay as patient

Stephen Black

Position
data scientist,
Organisation
black box data science
Comment date
11 December 2017

While the latest version of this analysis is useful, there are some points where the conclusions are not stated strongly enough and others where useful additional analysis has been missed. Here are a few examples.

The report claims the is only "limited evidence" that changes in the GP contract have led to increased numbers turning up at A&E. And the analysis says the major factor driving performance is admissions not attendances. A better way to describe the evidence would be to say there is no evidence at all that changes in GPs made any difference to A&E. And there is no relationship at all between the number of attendances and A&E performance. This emphasis is important as rather too much policy effort has been devoted to trying to reduce attendance despite there being clear evidence that this will make no difference whatsoever.

When it comes to staffing the report quotes the essential fact (A&E staffing has grown faster than demand for some years) but fails to draw the important conclusion that staff shortages are not the primary problem in A&E, at least nationally. There are other reasons that lead to this conclusion. One is that any analysis of why patients are delayed in A&E would show that the majority of delays are caused by factors outside the A&E (like a lack of free beds). More A&E staff don't help this blockage. Moreover, the workload in A&E (and the apparent need for more staff) is heavily driven by crowding which is, in turn, caused by those factors outside A&E. If the cause of crowding is fixed the A&E workload goes down. If we add more A&E staff and don't fix the blockage, then the workload will still be a problem but we will have wasted resources by applying them to the wrong place. Hospitals need to see emergency flow as a system not as a fragmented bundle of independent hospital departments. And investment needs to be made in the parts of the system that will unblock the flow. Investing in the wrong place will waste money without leading to improvement.

Here is a suggestion for a more insightful analysis of long waits. Don't look at the published 12hr trolley wait numbers: it is a game-able metric and very misleading. Look at the end-to-end 12hr wait (derivable from the A&E HES dataset). This is not gameable and is a far better indicator of how waits have deteriorated. There were (in 2016-17) about 250k 12hr waits (about 100 times more than 12hr trolley waits and pushing 2% of the type 1 attendance. This is a much more sensitive and more useful indicator of how bad things are than the discredited trolley-wait number.

In short: there are a lot of myths around A&E performance that need to be punctured so policy can focus on things that might actually work. Hedging the conclusions with too many caveats when the evidence is clear doesn't help. Be bold or the myths will resist and policy will continue to be ineffective.

Kate Silvester

Position
Doctor and Healthcare Systems Engineer,
Organisation
Kate Silvester Ltd
Comment date
19 December 2017

The number of patients waiting in any system is the most obvious and sensitive indicator of a System's performance. There are two reasons for an increasing number of patients waiting in the A&E system. 1) the workload (demand x the cycle time ((time from when a resource starts to process a patient to when the same resource is ready to process the next patient)) is greater than the staff time available at each resource or 2) there are policies or local 'rules' that govern the way the patients are processed that deliberately or unwittingly cause delays. While we would all like to believe that 'lack of resources' (staff, beds, machines) is the cause, unfortunately all the research shows that the latter is the most common and more unpalatable reason. Our healthcare managers do not know how to a) retrieve the data correctly to make the diagnosis and b) design healthcare systems to meet demand - as the unfortunate reference to '85% bed occupancy' in the above article reveals. Most beds are storage for patients while they wait for someone to start the next step in their care. So the number of beds in the system depends on the number of patients waiting for the flow resource. To prevent a queue, the flow resources need resilience capacity to cope with the variations in workload. So the rule of thumb of planning capacity at 85% of the variations in demand, applies to flow resource capacity, not storage.

While patient present with a variety of symptoms, the clinical process is very similar for many of them. It involves taking a history, examining the patient, making a clinical differential diagnosis, diagnostic tests (blood and other fluids, imaging) making the definitive diagnosis, prognosis and plan and then implanting the plan, reviewing the patient's progress against the prognosis and then maintenance. So how long does each step take? An experienced A&E consultant can take a quick history and examination within minutes and come up with the plan for diagnosis. This defines the clinical routing the patient requires and this is defined according to the longest step in the diagnostic part of the process - blood tests. If no blood test required, the patient needs the 'quick' stream often referred to as 'minors', and if a blood test is needed - the routing is referred to as 'majors'. So the majority of patients who require the minor process need 5 minutes of a history and examination, possibly an X-ray or Ultra sound (5 minutes) a diagnosis, prognosis and plan, then a prescription or treatment by a competent nurse /physiotherapy. They should be out of A&E in 20 minutes. For those requiring the major stream they will need a longer history and examination (40 minutes) a blood test (cycle time up to 1 hour) +/- imaging (cycle time 5 to 20 minutes) and definitive diagnosis, prognosis and plan (10 minutes). So now we can calculate how many man-hours are required to perform each task. And when we look at the resource available there are more than enough staff. So what's the problem? The policies: the policy of unwittingly designing the system to have a queue so we then have to reserve resource for the 'urgent patients', leaving others to wait, which further compromises the flow (as the chart above suggests). Then there are 'prioritisation' policies at every stage (GP receptionist prioritise patients calls, GPs do their home visits at lunchtime, the ambulance service prioritise, the hospital receptions staff prioritise, the doctors, nursing staff and porters prioritise, the labs prioritise, the imaging departments prioritise, and as a consequence the system is filled with queues at every stage. b) How about the staffing policies? We put the least experienced person on the front desk to define the routing (usually the receptionist), whereas if we put the consultant at this point the % of patients on the correct routing increases to over 95%, the junior doctors and nursing are guided as to what is required and are no longer overwhelmed. Instead of this simple process in which we need 2 consultants, 4 junior doctors 6 nurses and 9 trolleys to perform the majors process in < 2 hours at the periods of peak demand in a typical district general hospital, we have a series of junior doctors seeing the patient in sequence (rather than in parallel) and with all the delays in the system. As a consequence of all the delays and errors, the most senior and experienced staff can't provide the definitive diagnosis prognosis or plan until the next day. Many patients, particularly the elderly are whisked out into the next available bed without a diagnosis, prognosis or plan in order to 'hit the target'. Not only is this unsafe, but it causes massive rework and delays for patients and the staff downstream. So there are further delays the recovery and discharge where again priority occurs at every stage: discharges are done last after the ward rounds (which may only occur 2x week) as junior doctors focus on their sicker patients first, pharmacy batches and prioritises the prescriptions focusing on the inpatients first, as a result nurses can only organise relatives or other transport late in the afternoon or evening and the ambulance service prioritise the sick coming in over those going home. And then there is the extraordinary process for assessing the elderly and infirm for continuing health or social are funding which may only happen once a month.

Feedback.
A system is only as good as it's feedback loop (Gregory Bateson) and the feedback loop in the NHS is absent or at best delayed by months. Firstly the feedback occurs, if we are lucky, in retrospect once a month or quarter. Second the way the data is presented is by comparing one system with another rather than monitoring each system's performance continuously over time (as doctors do for a System in a hospital bed). Thirdly, the executive and senior mangers do not respond to the feedback signal. This is called Hubris and we, the public and press, collude in their Hubris by believing the yarn that the executive spin to hide their ineptitude.

So what do we need to? Train our managers, or better still encourage managers to find and recognise the skills they need. Unfortunately the science of operations management is unheard of in the NHS - we refer to operational research by academic institutions which takes months and is aimed to improve an authors or academic institution's research ranking in the light of their peers, not solving the problem. This is a chart of a System that tipped into 'chaos' in 2010. We need the data and the courage to consider the possibility that it was the interventions we made to the System that caused the problem and not keep 'blaming' those seeking our help and paying 50 % of the salary bill to the 20% of staff responsible for designing the system.

Alan Jones

Position
Patient,
Organisation
General Public
Comment date
11 January 2018

I glanced through your long article, and as a person (diabetic) aged over 80 I wish to point out that you ( and most of the younger (?) contributors, commentators, newspaper journalists, BBC local journalists, have omitted list or mention of the closures/diminishing of the very many excellent large general hospitals. It was via a short term, penny-pinching, cash from house-building greed/land grab frenzy (under both major governing parties) during recent decades. I recall mainly the Herts & Essex Hospital and Rye Street hospitals in Bishop's Stortford, Saffron Walden Hospital, etc. (Strategic also because close to M11, train line, and Stansted airport). Please ask a researcher and/or newspaper journalist to research and delineate which ones and number of beds UK-wide were lost. All A & E's and "cottage hospitals" are vital to local residents) which were lost. During the process of the slow winding down of the H&E hospital there were multiple protests and people declaiming for years "This closure is a crime!" The population of this particular area has massively increased, and thousands more houses are being built. Planning permission in the H&E area gets passed, even when nobody can get an appointment with a GP currently, and the Herts /Essex councils make no public mention of new GPs nor other medical facilities to be built commensurate with population size being included in "planning". Local Councils, Government and the "organisation" of GPs surgeries themselves hence do hold so much of the blame for the current crisis.

Mrs Nurse to be

Position
student,
Comment date
09 April 2018

this article does not have a date so I can't cite it correctly

awaters

Position
Digital Communications Assistant,
Organisation
The King's Fund
Comment date
09 April 2018

This article was published on 11 December 2017.
Kind wishes,
Anna

Vanessa

Position
Student,
Comment date
19 February 2019

Who is the author of this article? I can't cite him/her correctly
Thank you,
Vanessa

Ria

Position
Student,
Comment date
23 February 2019

I would also like to know the author(s) name(s) for a citation please.

smurphy

Position
Digital Content Producer,
Organisation
The King's Fund
Comment date
25 February 2019

Hi Vanessa and Ria,

Thanks for getting in touch. You will just need to put 'The King's Fund' as the author of this piece and include the publication date (2017) in your citation.

I hope that helps! If you have any further questions, please do not hesitate to get in touch.

Kind regards,
Sarah

OnlineMedicine…

Organisation
OnlineMedicineInfo.com
Comment date
27 March 2019

These times are calculated based on the average waiting times of patients in the previous four hour period. These times cannot be guaranteed and you may need to wait longer than the time shown.

John Mclinden

Position
Clinical Lead, Advanced Nurse Practitioner,
Comment date
18 May 2019

Thank you!

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